Vascular Uptake in Transforaminal Epidural Steroid Injections

Case Diagnosis: L3-L4 lumbar radiculopathy

Case Description or Program Description: A 65 year old female presented to the pain clinic with bilateral lumbar radiculopathy that has been present for several years, requiring multiple treatments including medications, conservative treatment, and neurosurgical intervention.

Setting: The patient presented to the pain clinic after undergoing and failing PT, Tylenol, NSAIDs, opiates, and Pregabalin. She also had a history of spinal cord stimulator and multilevel lumbar fusion. CT of the lumbar spine showed healed L4-L5 and L5-S1 fusions with multiple levels of neuroforaminal stenosis, most significant at L3-L4. Physical exam revealed loss of normal lumbar lordosis with tenderness along the lumbar paraspinals and lower lumbar facet joints. Her lumbar range of motion was limited with both flexion and extension, with pain accentuated during flexion. Motor strength testing indicated a 4/5 in the left lower extremity (L3 dermatome) and there was decreased sensation to light touch. Deep tendon reflexes were 2+ and symmetrical throughout the lower extremities.

Assessment/Results: The patient was referred to the interventional clinic for a bilateral L3-L4 transforaminal epidural steroid injection (TFESI). First, a right L3-L4 TFESI was performed without any complications. Then, upon injecting contrast for the left L3-L4 TFESI, vascular uptake was noted with flow entering into the aorta as confirmed by lateral imaging, therefore the procedure was aborted.

Discussion (relevance): The area of L3-L4 is the highest risk of vascular uptake due to the artery of adamkiewicz (Madhavan et al), therefore it is recommended that contrast first be injected to verify there is no vascular intrathecal uptake and that epidural spread is present. It is important to inject under live fluoroscopy, using digital subtraction angiography if available.

Conclusions: It is of the utmost importance to use a nonparticulate steroid at this level, as if one were to miss vascular uptake on contrast, injecting a particulate could be detrimental.